Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Department of Rheumatology, Immunology and Allergology, University Hospital and University of Bern, Switzerland.
Lancet. 2016 May 21;387(10033):2093-2105. doi: 10.1016/S0140-6736(16)30002-2. Epub 2016 Mar 18.
BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are the backbone of osteoarthritis pain management. We aimed to assess the effectiveness of different preparations and doses of NSAIDs on osteoarthritis pain in a network meta-analysis. METHODS: For this network meta-analysis, we considered randomised trials comparing any of the following interventions: NSAIDs, paracetamol, or placebo, for the treatment of osteoarthritis pain. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the reference lists of relevant articles for trials published between Jan 1, 1980, and Feb 24, 2015, with at least 100 patients per group. The prespecified primary and secondary outcomes were pain and physical function, and were extracted in duplicate for up to seven timepoints after the start of treatment. We used an extension of multivariable Bayesian random effects models for mixed multiple treatment comparisons with a random effect at the level of trials. For the primary analysis, a random walk of first order was used to account for multiple follow-up outcome data within a trial. Preparations that used different total daily dose were considered separately in the analysis. To assess a potential dose-response relation, we used preparation-specific covariates assuming linearity on log relative dose. FINDINGS: We identified 8973 manuscripts from our search, of which 74 randomised trials with a total of 58,556 patients were included in this analysis. 23 nodes concerning seven different NSAIDs or paracetamol with specific daily dose of administration or placebo were considered. All preparations, irrespective of dose, improved point estimates of pain symptoms when compared with placebo. For six interventions (diclofenac 150 mg/day, etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day), the probability that the difference to placebo is at or below a prespecified minimum clinically important effect for pain reduction (effect size [ES] -0·37) was at least 95%. Among maximally approved daily doses, diclofenac 150 mg/day (ES -0·57, 95% credibility interval [CrI] -0·69 to -0·46) and etoricoxib 60 mg/day (ES -0·58, -0·73 to -0·43) had the highest probability to be the best intervention, both with 100% probability to reach the minimum clinically important difference. Treatment effects increased as drug dose increased, but corresponding tests for a linear dose effect were significant only for celecoxib (p=0·030), diclofenac (p=0·031), and naproxen (p=0·026). We found no evidence that treatment effects varied over the duration of treatment. Model fit was good, and between-trial heterogeneity and inconsistency were low in all analyses. All trials were deemed to have a low risk of bias for blinding of patients. Effect estimates did not change in sensitivity analyses with two additional statistical models and accounting for methodological quality criteria in meta-regression analysis. INTERPRETATION: On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose. We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients. FUNDING: Swiss National Science Foundation (grant number 405340-104762) and Arco Foundation, Switzerland.
背景:非甾体抗炎药(NSAIDs)是骨关节炎疼痛管理的基础。我们旨在通过网络荟萃分析评估不同制剂和剂量的 NSAIDs 对骨关节炎疼痛的疗效。
方法:在这项网络荟萃分析中,我们考虑了比较以下任何干预措施的随机试验:NSAIDs、扑热息痛或安慰剂,用于治疗骨关节炎疼痛。我们搜索了 Cochrane 对照试验中心注册库(CENTRAL)和相关文章的参考文献,以获取 1980 年 1 月 1 日至 2015 年 2 月 24 日发表的试验,每组至少有 100 名患者。预设的主要和次要结局是疼痛和身体功能,并在治疗开始后最多 7 个时间点进行重复提取。我们使用扩展的多变量贝叶斯随机效应模型,对具有试验水平随机效应的混合多治疗比较进行分析。对于主要分析,为了考虑到试验内的多个随访结局数据,使用了一阶随机游走。在分析中,将使用不同总日剂量的制剂分别考虑。为了评估潜在的剂量-反应关系,我们使用了特定制剂的协变量,假设对数相对剂量呈线性。
发现:我们从搜索中确定了 8973 篇论文,其中 74 项随机试验共纳入了 58556 名患者。考虑了 7 种不同 NSAIDs 或扑热息痛或安慰剂的 23 个节点,具体剂量各不相同。与安慰剂相比,所有制剂(无论剂量如何)都改善了疼痛症状的点估计值。对于六种干预措施(双氯芬酸 150mg/天、依托考昔 30mg/天、60mg/天和 90mg/天,以及罗非昔布 25mg/天和 50mg/天),与安慰剂差异达到或低于预先指定的最小临床重要疼痛缓解效应(效应大小[ES]-0.37)的概率至少为 95%。在最大批准日剂量中,双氯芬酸 150mg/天(ES-0.57,95%置信区间[CrI]-0.69 至-0.46)和依托考昔 60mg/天(ES-0.58,-0.73 至-0.43)最有可能成为最佳干预措施,两者都有 100%的概率达到最小临床重要差异。随着药物剂量的增加,治疗效果增加,但对塞来昔布(p=0.030)、双氯芬酸(p=0.031)和萘普生(p=0.026)的线性剂量效应进行的相应检验具有统计学意义。
我们没有发现治疗效果随治疗时间而变化的证据。在所有分析中,模型拟合良好,异质性和不一致性低。所有试验均被认为对患者的盲法具有低偏倚风险。在使用两种额外的统计模型进行敏感性分析和在荟萃回归分析中考虑方法学质量标准时,效应估计值没有改变。
解释:根据现有数据,我们认为在目前,不论剂量如何,单一用药扑热息痛对治疗骨关节炎患者均没有作用。我们提供了有力的证据,表明双氯芬酸 150mg/天是目前最有效的 NSAIDs,在改善疼痛和功能方面均有效果。然而,鉴于这些药物的安全性特征,医生在选择制剂和剂量时,需要将我们的结果与所有已知的安全性信息结合起来,以满足个体患者的需求。
资金:瑞士国家科学基金会(授予编号 405340-104762)和瑞士阿科基金会。
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